Provider Demographics
NPI:1750387601
Name:SHORE, ERIC EUGENE (DO)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:EUGENE
Last Name:SHORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 W DARTMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2520
Mailing Address - Country:US
Mailing Address - Phone:610-664-4182
Mailing Address - Fax:610-664-4372
Practice Address - Street 1:3939 CONSHOHOCKEN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5400
Practice Address - Country:US
Practice Address - Phone:215-877-7400
Practice Address - Fax:215-877-7479
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-003157-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0830344Medicaid
PA129710Medicare ID - Type Unspecified
PA0830344Medicaid